The World Health Organization1 identified harm reduction programs, such as needle and syringe programs, as a key component of comprehensive HIV prevention programming for people who use drugs. Over the past 20 years, the scientific evidence about how best to deliver these programs has grown in quantity and sophistication. To make sure that Canadian programs keep pace with emerging evidence, a new best practice recommendations document is now available for harm reduction programs that provide services to people who use drugs.

What Is the Best Practice Recommendations Project?

Community service providers identified a pressing need for cross-Canada best practice recommendations that focused on needle exchange programs and smoking/inhalation programs. There was a great desire to integrate recommendations and innovations from the most current evidence into their practice. While earlier recommendations were released by some provinces, Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People who Use Drugs and are at Risk of HIV, HCV and Other Harms: Part 12 was developed for programs nationally (Part 2 is under development -- see below). The aim of this project is to promote consistent, high-quality, harm reduction services to people who use drugs in Canada.

The Working Group on Best Practice for Harm Reduction Programs in Canada who prepared this document is a cross-Canada, multi-stakeholder team with representation from researchers, service providers, policy makers, and people with lived experience/who use drugs. Best Practice Recommendations: Part 1 features up-to-date scientific evidence about risk, behaviours and prevention of HIV, hepatitis C, hepatitis B and other harms.

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How Are Needles Used to Inject Drugs?

There are various ways that people can use drugs -- injection is just one. Typically, injection is used by some people who use drugs because of the immediate effect and the intense high created. For someone to inject a drug, it must be mixed with water in a container (such as a "cooker" or spoon, or occasionally directly in the syringe). Sometimes this solution is heated while other times it is not. The solution is then drawn through a filter through the needle and into the syringe. The person's skin is cleaned and a tourniquet used to help find the vein to be injected.

Potential Health Issues With Needle Use

One of the potential problems with injecting is that it can lead to blood-to-blood contact between people if sharing of needles/syringes or other injecting equipment occurs. Blood-to-blood contact increases the risk of acquiring and/or transmitting HIV, hepatitis C and hepatitis B. Another potential problem is that any impurities or contaminants in or on the drugs and equipment can lead to skin and vein problems and other infections.

How Can Needles Transmit HIV, Hepatitis C and Hepatitis B?

Studies have looked at whether or not HIV, hepatitis C and hepatitis B can survive in needles. The viruses must be able to survive in order for transmission to occur. Research has shown us that HIV can survive in blood in needles for up to 30 days or more and that this is affected by factors such as volume of blood, temperature and duration of storage.3-5 Furthermore, needles collected from places where people inject within the community (e.g., "shooting galleries") have shown evidence of HIV6-9 so we know that it is possible for HIV to be present in needles.

Compared to HIV, hepatitis C is 10-times more easily transmitted through a contaminated needle.10,11 Research has shown that hepatitis C can survive for up to 63 days in needles.12 Hepatitis C has also been detected in used needles and injecting equipment collected from community locations.13

Compared to HIV, hepatitis B is 100-times more infectious.14 Hepatitis B is also resilient and easily transmitted via needle sharing. At room temperature, hepatitis B can survive in dried blood for at least a week.15 The Public Health Agency of Canada has reported that hepatitis B can survive in dried blood for weeks and remain stable on surfaces for at least a week.16

In light of these risks, the Working Group recommends that harm reduction programs distribute needles (and also other injection equipment) to facilitate the use of a sterile needle and syringe for each injection.

So How Many People Who Inject Drugs Have HIV, Hepatitis C and Hepatitis B in Canada?

Across Canada, the prevalence of HIV among people who inject drugs, as observed with data from a large study was 13%, ranging from 3% in Regina to 24% in Edmonton.17 The study also found that life-time prevalence (current or past infection) of hepatitis C was 66%, ranging from 62% in Winnipeg to 69% in Sudbury and Victoria.17 Much like HIV, hepatitis C prevalence varies across regions.

According to national 2011 HIV estimates, up to 16% of all new HIV infections in Canada (incidence) may have been due to injection drug use.18 This estimate includes 435 new HIV infections attributed to injection drug use and 80 new HIV infections attributed to either injection drug use or men having sex with men (because the person participated in both behaviours prior to HIV diagnosis). A high proportion of new HIV infections among Aboriginal people and women were likely due to injection drug use. According to national 2011 HIV estimates, 58% of the estimated new HIV infections in Aboriginal people were attributable to injection drug use.18 Among women, 23% of the estimated new HIV infections were attributable to injection drug use.18

According to national 2007 hepatitis C estimates (the most recent year for which we have data), there were 7,945 new hepatitis C infections, of which 83% were attributable to injection drug use.19

There is limited data on hepatitis B among injection drug users in Canada. However, according to the Enhanced Hepatitis Surveillance Strain System, injection drug use accounted for 12% of all new hepatitis B infections between 2005 and 2010.14

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